Provider Demographics
NPI:1346245115
Name:BRESSACK, MITCHELL L (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:L
Last Name:BRESSACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 W 94TH PLACE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1710
Mailing Address - Country:US
Mailing Address - Phone:219-662-8822
Mailing Address - Fax:219-662-8833
Practice Address - Street 1:70 W 94TH PLACE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1710
Practice Address - Country:US
Practice Address - Phone:219-662-8822
Practice Address - Fax:219-662-8833
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059363207N00000X
IN01031629207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100214910AMedicaid
IN020007477Medicare PIN
IN234710BMedicare PIN